Licenciado sob uma Licença Creative Commons DO): http://dx.doi.org. . / - . . .AO
[T]
Epidemiological profile of workers with musculoskeletal
disorders of a supermarket company
[)]
Peri l epidemiológico dos trabalhadores com distúrbios
musculoesqueléticos de uma rede de supermercados
[A]
Marcia Benites da Silva[a], Caren Lara Martins Picasso[a], Miriam Pilla Rosito[b]*
[a] Universidade Feevale, Novo (amburgo, RS, Brazil
[b] Pontifícia Universidade Católica do Rio Grande do Sul PUCRS , RS, Brazil
[R]
Abstract
Introduction: The epidemiological profile is considered a sensitive indicator of living conditions and the
disease process. The musculoskeletal disorders are the most common causes of pain and can lead to dis-ability or restriction of daily activities. These disorders take the name of RCT/OWRD when they are as-sociated with work activities and may be asas-sociated with risk conditions at work. Objectives: To describe
the epidemiological profile of supermarket workers with musculoskeletal disorders under treatment at a physiotherapy clinic in the city of Porto Alegre, Brazil. Methods: This was a cross-sectional, observational
study which used retrospective data collected from records of patients treated from January to December in a physiotherapy clinic that provides health services for a supermarket chain. Results:
There was a predominance of females . % , aged – years . % ; . % reported being single and
. % lived in Porto Alegre. The most commonly reported occupation was cashier . % . The main rea-sons for referral to physiotherapy treatment were low back pain . % , neck pain . % , pain . % , subacromial bursitis . % and back pain . % . Among the signs and symptoms . % of the sample reported pain in chronic phase. Conclusion: The prevalence of musculoskeletal pain was high in this group.
The presence of pain can disable the worker for daily activities and physiotherapy becomes the therapeutic procedure of choice for their rehabilitation.
[P]
Keywords: Occupational health. Occupational injuries. Physiotherapy. Musculoskeletal pain.
]
[B]Resumo
Introdução: O perfil epidemiológico é considerado um indicador sensível das condições de vida e do processo saúde-doença. Os distúrbios musculoesqueléticos são as causas mais frequentes de dor e podem levar à incapa-cidade ou limitação das atividades diárias. Esses distúrbios, quando associados ao trabalho, levam o nome de LER/DORT e podem estar associados às condições de riscos no trabalho. Objetivos: Traçar o perfil epidemioló-gico dos trabalhadores com distúrbios musculoesqueléticos de uma rede de supermercados, atendidos em uma clínica de fisioterapia de Porto Alegre (RS). Materiais e métodos: Estudo de corte transversal, observacional, com coleta retrospectiva de dados de 360 prontuários de pacientes atendidos no período de janeiro de 2010 a dezembro de 2011 em uma clínica de fisioterapia que presta serviços de saúde para uma rede de supermer-cados. Resultados: Houve predomínio do gênero feminino (73,9%), na faixa etária dos 30–39 anos (35,1%); 63,0% declararam-se solteiros e 73,4% residentes em Porto Alegre. Em relação à ocupação, a maior frequência foi para o setor frente de caixa (31,2%). Os principais motivos de encaminhamento para a fisioterapia foram lombalgia (21,4%), cervicalgia (19,7%), dor (16,1%), bursite subacromial (13,9%) e dorsalgia (12,2%). Dentre os sinais e sintomas, 95,8% da amostra mencionou a dor em fase crônica. Conclusão: A prevalência de dor musculoesquelética foi alta neste grupo. A presença de dor pode incapacitar o indivíduo para atividades diá-rias e laborais. A fisioterapia tornou-se o procedimento terapêutico eleito para sua reabilitação. [K]
Palavras-chave: Saúde do trabalhador. Lesões ocupacionais. Fisioterapia. Dor musculoesquelética.
Introduction
Epidemiological research is based in the study of the distribution and determinants of events or health patterns in populations, and the use of research to control health issues . Epidemiological profile can be considered as a relatively sensitive indicator of living conditions, health and disease processes and population patterns. According to Brazilian Law No. , / , health presents determining and condition-ing factors such as eatcondition-ing habits, livcondition-ing conditions, wa-ter and sanitation, the environment, work, income, education, transportation, and leisure, among others, and these are also factors that are responsible for shap-ing the profile of a community, which must occur with a clear compromise with the transformation of the health conditions of the population, favoring the devel-opment of a health system that understands the health and disease process as part of social organization .
Population increase, the incorporation of new technologies and work intensification have brought consequences such as an expressive ) injury increase among the working class. These injuries, classified as RS)/WMSDs Repetitive Strain )njury and Work-related Musculoskeletal Disorders , refer to mus-culoskeletal changes associated with occupational activities and risk conditions at work .
Musculoskeletal disorders MSDs are character-ized by inflammation and/or degeneration of mus-cles, bones, joints, tendons, ligaments, bursa, fascia, connective tissue, cartilage and aponeurosis. They are the most frequent cause of pain and may result in disability or limitation for daily activities , , .
consequence is a decrease in productivity which results from the reduction of the work force due to employee’s medical leave and work repositioning or work adaptations for employees that return to work after a medical leave. This results in substantial im-pact on healthcare quality and costs .
RS)/WMSDs present a multi-causal dimension and biomechanical, physiological and psychologi-cal factors are among the main causing factors. Biomechanical factors involve inadequate adverse posture; mechanic compression and repetitiveness. Physiological factors include hormone changes; the bone and joint structure of each individual worker; obesity; general health status, height, among oth-ers. Psychological factors refer to stress, individual psychological profile as well as social relations. All of these factors make occupational disease a complex and degrading condition for an individual, directly influencing the balance between body and mind and the individual’s socioeconomic and cul-tural scenario .
)n , according to data from the Ministry of Social Security , cases of work related accidents were reported in Brazil. These incidents were qualified as typical due to characteristics
re-lated to the professional activity carried out by the employee , commute accidents with took place while
worker was commuting to and from work and
occu-pational disease caused by any type of occupational
disease related to professional activities listed by Social Security services . )n the same year, the state of Rio Grande do Sul registered , cases, of which
, occurred in the city of Porto Alegre.
(ealth aggravations due to work related accidents may or may not cause temporary or permanent dis-ability. Thus, the rehabilitation of workers becomes one of the greatest contemporary challenges for pub-lic health in Brazil .
According to the Brazilian Physiotherapy and Occupational Therapy Federal Council on Resolution No. , dated December , :
Attributions of the physiotherapist who provides health care for workers, regardless of working place, include: […] identifying, evaluating and ob-serving environmental factors which may constitute risks to a worker’s functional health, in any stage of the production process, alerting the employer as to the existence of these risks and possible results; carrying out the biomechanical analysis of worker’s
productive activity, considering different task de-mands on static and dynamic efforts […] .
Epidemiological evidence by the Ministry of Social Security on medical leave due to accidents is expressive — be these typical, commute or
occu-pational disease accidents —, as well as regulating
interventions proposed by the Ministry of (ealth, with the Occupational (ealth National Policy, which seeks to reduce accidents and occupational diseases by stimulating health promotion, rehabilitation and surveillance measures.
Assessment of professional, working conditions and occupational stress profiles may subsidize pro-grams to adequate the work process . Keeping this perspective in mind, the objective of this study was to identify the epidemiological profile of super-market workers treated for musculoskeletal disor-ders at a physiotherapy clinic in the city of Porto Alegre, Brazil.
Materials and method
A cross-sectional observational study was car-ried out using retrospective data collection from patient records.
The study analyzed the records of patients treated from January to December in a physical therapy clinic located in the city of Porto Alegre, Brazil. This clinic is part of a multidisciplinary team of a company that provided healthcare services for a supermarket chain.
)n order to be included in the study, the record being analyzed had to be from a patient with a proven employment relationship with the supermarket chain and a musculoskeletal disease as the reason for refer-ral and/or by physiotherapy evaluation. Records that were excluded from the study belonged to patients that presented with a musculoskeletal disorder that was not related to their work activity.
)n order to identify the workers’ sociodemograph-ic profile, the following data was collected from the records: age, sex, marital status, city of residence, occupation and work location branch store within the supermarket chain .
Regarding city of residence, . % reported liv-ing in Porto Alegre, while the other . % remain-ing participants reported livremain-ing in the Porto Alegre Metropolitan Area, with special mention to the cit-ies of Alvorada . % , Viamão . % and Canoas
. % .
When occupation was analyzed, greater fre-quencies were noted in occupations such as cashier
. % , as well as occupations performed in the bakery and warehouse, representing . % of total sample Graph . Work performed at cash registers involves duties such as a cashier, cashier assistant and supervisor, security and support. )n this study, working at the bakery involves occupations such as baker and confectioner and working at the ware-house involves occupations that deal with sorting and carrying merchandise, stocking, replacing and checking products.
As to work location, . % of workers were sta-tioned in stores in Northern Porto Alegre, . % in the stores in Southern Porto Alegre, . % in the Eastern part of the city and . % in the Porto Alegre Metropolitan Area.
Type of funding for physiotherapy treatment was exclusively provided by supplementary health insur-ance . % . Most physician referrals were due to low back pain . % , neck pain . % , pain . % , subacromial bursitis . % and back pain . % Graph .
)n addition, . % of referring physicians worked as orthopedic/traumatology physicians.
Regarding signs and symptoms, pain was referred by . % of the sample. Also, . % of participants reported muscle contracture, . % limited range of motion ROM , . % edema and . % loss of muscle strength Graph .
As to stage of injury, . % of participants pre-sented with chronic injuries, . % with sub-acute injuries and % with acute injuries. Time of onset of signs and symptoms was more prevalent for periods of up to month . % and for periods of to months . % Graph .
Complementary exams showed that . % of participants had been submitted to X-Ray, . % to ultrasound and . % to nuclear magnetic resonance and electromyoneurography.
The most prevalent physiotherapy techniques used to treat patients were kinesiotherapy . % , electrothermal and phototherapy . % and cryo-therapy . % Graph .
to information found on patient records and special-ty of physician that referred patient to physiotherapy. Signs and symptoms were investigated from data provided by the (istory of the Present )llness (P) and Physical Examination sections on the pa-tient records. Reported musculoskeletal disorders were then classified as acute, sub-acute or chronic
according to time of onset of signs and symptoms described in (P), and classified according to Robbins et al. .
Complementary exams, information whether or not the worker was engaged in work activity at the time, if he/she was in medical leave or had been re-ferred to The National )nstitute for Social Security
N)SS at the date of kinesiotherapy evaluation, as well as the number of sessions per patient were de-scribed according to data found on the records.
Physiotherapy treatment was group according to treatment technique: cryotherapy — the therapeu-tic use of cold; electrothermal and phototherapeu-tic — the use of electricity, hear and light to treat disease, and kinesiotherapy — the use of exercises for rehabilitation.
Data was collected, typed into a table using the Microsoft Excel™ software and then submitted to statistical analysis through software SPSS . . Significance level α of % was used as a deci-sion criteria.
This study was submitted to the Ethics Committee at Feevale University and approved on September , under Report No. , , Plataforma Brasil/
CAAE . . . .
Results
Results refer to a sample of participants. There was a significant p < . predominance of females . % in relation to males . % . Average age was . ± . years, with a minimum age of years and a maximum age of years. There was a significantly high p < . proportion of participants between the ages of and years . % and between the ages of and years . % when age was analyzed by age groups. For marital status, the group that declared to being single was more significant p < . , with . % of participants. Among others, . % declared to being married, . % divorced, . % separated and
Graph 1 – Occupations (%)
Graph 2 – Reason for physician referral Graph 3 – Signs and symptoms
Graph 4 – State of injury Graph 5 – Physiotherapy treatment
Back pain Low back pain
Neck pain Subcromial bursitis
Pain 25
20
15
10
5
0
Costumer ser vice
Administrative assistantCash register suppor t
Warehouse
Store/Branch manager Security
Restaurant Ba kery
Home supplies and appliances Textiles/P
ersonal... Groceries Butcher Cleaning Cold cuts
Fruits and vegetables Others 35
30 25 20 15
10
5 0
120
100
80
60
40
20
0
Pain Muscle contracture
Limited ROM
Edema Muscle strength loss
4%
12,50%
Acute Sub-acute Chronic
83,60%
120
100
80
60
40
20
0
Kinesiotherapy Electrothermal and phototherapy
The average number of physiotherapy sessions was nine. Looking at groups of sessions, the most prevalent was from one to five sessions . % and from six to ten sessions . % . )n addition, . % of participants were treated for over physiother-apy sessions.
Regarding employment relationship, . % of participants were actively working, . % had been referred to The National )nstitute for Social Security N)SS , . % were on medical leave and . % were on vacation at the time of kinesiotherapy evaluation.
The presence or absence of pain was compared to gender and a statistically significant association p < . was found, showing the association between the female sex and pain. No significant association p > . was found when pain was compared to age groups, showing that pain does not depend on age for this sample. )n addition, the most commonly afflicted age group was to years, followed by to years for both the group that referred pain and the group without pain.
When pain was compared to work location, no significant statistic association was found p > . When occupation was compared to pain a significant statistic association was found p < . , showing that cash register support workers are associated to pain in a significant way, while the association oc-curred without the presence of pain for warehouse and grocery employees. There was no significant as-sociation for other occupations due to small sample size.
Discussion
The present study found a higher concentration of single women between the ages of to years and to years who reside in the city of Porto Alegre, in Southern Brazil, and who worked mainly as cash register support in stores located in the Northern and Southern regions of this city. These women were associated with the presence of pain.
According to the Monthly Employment Research MER carried out in in six Brazilian metro-politan areas Recife, Salvador, Belo (orizonte, Rio de Janeiro, São Paulo and Porto Alegre , the female population represents the most active working-age population WAP , with . % of employed women, and over the past years this behavior has remained the same for all six metropolitan areas as well as for each area individually. )n Porto Alegre and the Porto
Alegre Metropolitan Area, the WAP was com-posed by . % of females and . % males . Women represented up . % of the occupied pop-ulation. This percentage is even higher when com-pared to the WAP, however, according to the Brazilian )nstitute for Geography and Statistics, participation of women in the occupied population has a tendency to increase . percentage points in relation to .
)n , data from the MER showed that the dis-tribution of the working-age population in the Porto Alegre metropolitan area according to age group, re-ported . % of individual between and years and . % of individuals between and years in . The occupied population was . % and . % respectively, data which corroborates with the age group that makes up the socio-demographic profile found for the sample in this study .
According to Santos , RS)/WMSDs are not an exclusively female condition, but affects mainly wom-en who work in positions where repetitive momwom-ents are dominant, with higher demand of attention, manual skills, dexterity and control over productiv-ity. Ferreira et al. tried to determine the preva-lence of chronic low back pain in a population base adult sample residing in the city of Pelotas, Southern Brazil, and verify association with demographic, so-cioeconomic, behavioral ergometric and nutritional variables. The author found that among the , individuals in the study, prevalence of chronic pain was higher among females . % . This is similar to data found in a study conducted in the Netherlands, which showed the predominance of chronic pain in women . % , and to a study involving the popula-tion of the city of Salvador, where . % of individu-als presenting with chronic pain were females . Women have a greater risk than man for chronic low back pain. Some studies attribute this finding to an information bias. (owever, this finding is plau-sible, since women combine home tasks with the work outside of the home, where they are exposed to ergonomic loads, especially repetitiveness, problem-atic working positions and work carried out at high speed. Besides, females present certain anatomical/ functional characteristics which may contribute to chronic low back pain shorter stature, less muscle mass, less bone mass, more fragile joints that are less adapted to heavy physical strength, higher fat weight .
Participants in this study presented with higher back pain complaints and when authors tried to cor-relate these findings with the most commonly per-formed complementary exams, they found that most referrals to physiotherapy treatment had been made by orthopedic physicians, which can be related to fewer MR)s, due to greater specificity during clinical care, as well as the high cost and need for previous authorization by the healthcare insurance company to have exam performed. According to Matos and Gusmão , MR)s are in fact not necessary for all patients with radiculopathy. This exam is reserved for cases where image will guide treatment, which is useful for patients with neurological signs and symptoms such as lameness and a suspected cen-tral or foraminal stenosis. Although it is indicated in restricted situations, requests for this exam hap-pen in over % of low back pain cases. Bearing in mind that the first professional to have contact with these patients is usually not a specialist, the increase on MR) prescription may lead to overestimating its real value. This causes a high and unnecessary cost increase for the healthcare system and also induces diagnostic and therapeutic mistakes in case of false-positives and or false-negatives.
X-rays and ultrasounds are the most prevalent complementary exams found in this study. X-ray is the initial choice exam since it presents less op-erational costs, it is highly available and allows for evaluating fractures, luxations, degenerative pro-cesses, posture changes, tumors, etc. Ultrasound is a fundamental diagnostic method in evaluating musculoskeletal conditions in urgent care, assuring diagnostic and therapeutic resolution. Ultrasound enables detecting and characterizing soft tissue inju-ries, especially muscle, tendon and ligament injuinju-ries, and may also be used for searching foreign bodies, as well as screening .
Another characteristic of the sample is the higher frequency of employed workers normally carrying out their work activities, even with the high prevalence of pain. Musculoskeletal disorders may cause great impact and findings such as reported pain . % , muscle contracture . % , range of movement limitation . % , edema . % and decrease in muscle strength . % confirm this affirmation. Physiotherapy is widely prescribed for the treatment of these conditions as its main objective is to restore physical function. Patients underwent an average of nine physiotherapy sessions and most commonly insurance that is offered by employer in order to
fund physiotherapy treatment. Most patients were referred to physiotherapy treatment by an orthope-dic/traumalogy physician, which suggests a more specialized clinical diagnosis, since this is the medi-cal area that studies disease and deformity of the locomotor system, as well as trauma related to the musculoskeletal system.
When characteristics of workers presenting with musculoskeletal disorders were collected, the study found a greater occurrence of neck and upper limb pain, which is a finding confirmed by previous studies.
Santos verified the prevalence of pain in cashiers and stockers employed at stores from a supermarket chain in the city of Caxias do Sul, Southern Brazil, with a total of workers fe-males and fe-males and found that % of cashiers reported upper limb pain, % low back pain and % neck pain. Among stockers, % reported low back pain, % upper limb pain and % neck pain. Galvão tried to identify factors related to health and life quality in the work environment of super-market cashiers in the city of Paraíso do Tocantins, state of Tocantins. All participants were women and % reported work related pain, with over half of participants reporting back pain. Batiz et al. studied eight supermarkets in two different cities in Brazil to identify risk factors to which supermarket cashiers were exposed. The population of this study was composed of workers between to years and . % were females. When complaints for this population were studied, the author found that % of participants reported low back pain, % shoulder pain, % back pain and % neck pain.
Chronic pain was among most frequent signs and symptoms. Some participants reported more than one pain complaint, for example: irradiating pain, pain lo-cated in a specific body part, pain during movement, pain while performing activities of daily living, etc.
Garcia and Torres Neto determined the clin-ical profile of employed patients and those under medical leave who were being treated at a chronic pain outpatient care unit at the Federal University of the state of Maranhão university hospital from to . About % of patients were employed and
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used therapeutic resources were the association of kinesiotherapy techniques with electrothermal and phototherapy and cryotherapy.
Patients with RS)/WMSDs are frequently referred to physiotherapy services. Many times, this is the first and sole therapeutic procedure and may be long term . Physiotherapists are qualified and legally apt to contribute towards prevention, promotion and res-toration of workers’ health with relevant preventive and therapeutic measures to reduce occupational diseases .
Data collection based on patient records review present strong limitations such as: lack of filling out and registering important information or missing information , for example, missing therapeutic outcome: patient was released from treatment or abandoned it; missing information on length of ser-vice. These were considered limitation factors for this study.
Conclusion
Prevalence of musculoskeletal pain among em-ployees of a supermarket chain treated at a physio-therapy clinic in the city of Porto Alegre/Southern Brazil from January to December was high . % and more prevalent in women . % be-tween to years . % and to years
. % residing mainly in the city of Porto Alegre/ Southern Brazil, who were employed providing cash register support services, users of the complementary healthcare insurance provided by the employer and referred to physiotherapy treatment by an orthopedic physician. These women reported pain, limitation of range of movement, muscle contracture and edema. An association of kinesiotherapy, electrothermal and phototherapy and cryotherapy was used to provide physiotherapy treatment.
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